New Student Application

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STUDENT INFORMATION:

Please complete a separate application for each student applying)

Name(Required)

First Last

Gender(Required)

Male

Female

Date of Birth(Required)

MM slash DD slash YYYY

School Last Attended(Required)

Grade Level Requested(Required)

We were referred by:

Father's Information

Father's/Guardian's Name

First Last

Father's Email Address

Father's Cell Phone #

Mother's Information

Mother's/Guardian's Name

First Last

Mother's Email Address

Mother's Cell Phone #

Family Information

Family Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Telephone #(Required)

Marital Status

Married

Divorced

Remarried

Separated

Widow/Widower

Single

If divorced, who has legal custody?

Father

Mother

Joint

Other

Children In family of school age

Name

Age

Children not applying to Eukarya Academy

Reason They Are Not Applying

Religious Information

Church Attending

Pastor

Church Address

Church Phone

Father, Born-Again Christian (John 3:3-5)

Yes

Mother, Born-Again Christian (John 3:3-5)

Yes

Has the applicant ever made a profession of faith in Christ?

Yes

What goals do you have in mind for the training and development of your child(ren) as individuals?

What are your reasons for wanting to enroll your child at Eukarya Christian Academy?

Academic and Behavioral Information

Last School Attended

Last Grade Completed

Is student eligible to return to all previously attended schools?

Yes

If no, please explain

What subject(s) does your child enjoy and excel in?

What causes your child to feel especially good about herself or himself?

Has this child ever been suspended, dismissed, or refused admissions to another school?

Yes

If yes, please explain

Has this child ever been bullied or been disciplined for bullying?

Yes

If yes, please explain

Please indicate if any of the following apply to the previous school, to the home, or to other instances

Behavioral and/or disciplinary problems

Placed on probation

Explain

Has the Student Ever Skipped a Grade?

Yes

Has the Student Ever Repeated a Grade?

Yes

If yes, please explain

If calling your previous school, what comment could we anticipate?

Good student

Discipline problem

Struggling learner

Please indicate the academic level of student's previous work

Excellent

Good

Average

Poor

Academic and Behavioral Information Continued

What are your child’s interests outside of school?

In what manner does your child learn best? For example, hearing, seeing, doing, or questioning.

Is there anything you feel we should know about your child in order to effectively work with him/her?

Are there areas of your child's education about which you have specific concerns? How would you see him/her improve?

Does the applicant have any obstacles in the following areas that may affect his/her activities or progress?

Mental

Emotional

Physical

If yes, please explain

Has your child participated in a 504 or IEP?

Yes

Please describe

Has your child worked with any of the following (please check any/all that apply)

Reading specialist

Speech therapist

Physical therapist

Occupational therapist

Behavioral therapist

Please describe

Is or has the student been under the care of a Psychologist/Psychiatrist?

Yes

Is he/she currently on any type of medication?

Yes

If so, please List

Please check area(s) that the student has been tested and include date(s) or age(s) when the diagnosis was received

Speech/Language

Attention Deficit/Hyperactivity Disorder

Attention Deficit Disorder

Dyslexia

Autism Spectrum Disorder

Learning Disabilities

Communication Delay

Occupational Therapy

Neuropsychological Evaluation

Educational Psychological Evaluation (Ed Psych)

Other

Date of Speech/Language Diagnosis

Date of Attention Deficit/Hyperactivity Disorder Diagnosis

Date of Attention Deficit Disorder Diagnosis

Date of Dyslexia Diagnosis

Date of Autism Spectrum Disorder Diagnosis

Date of Learning Disabilities Diagnosis

Date of Communication Delay Diagnosis

Date of Occupational Therapy Diagnosis

Date of Neuropsychological Evaluation Diagnosis

Date of Educational Psychological Evaluation (Ed Psych) Diagnosis

Give a date and describe the other relevant diagnosis

Is the student currently or have they previously seen a professional for any of these diagnoses?

Yes

If yes, please provide the name of the professional(s)

Is there any other information you would like to share about your child?

Additional Information

For students that are 12 years of age or older, please provide a written/typed statement of your testimony. Include how you came to accept Christ as your personal savior and what you are currently doing to grow in your relationship and faith.

Please provide three references on the included sheets. Please include one educational reference (teacher, principal, aide, etc.) and two personal/pastoral references from church/coach/job/club/extracurricular, etc. These references should be current and should know the student personally. Please do not list immediate family as references.

Educational Reference

Name

First Last

Phone

Relationship to Student

Personal/Pastoral Reference

Name

First Last

Phone

Relationship to Student

Personal/Pastoral Reference

Name

First Last

Phone

Relationship to Student

Certification of Information

We hereby certify that the above answers are true and are made with no reservations beyond those in the attached explanations.

Father/Guardian Signature

Date

MM slash DD slash YYYY

Mother/Guardian Signature

Date

MM slash DD slash YYYY

Please include a $75.00 non-refundable application fee when returning this application. Upon enrollment, the application fee will be applied toward the enrollment fee.

Eukarya Family Center Inc. admits students of any race, color, creed, and ethnic origin to all the rights and privileges, programs, and activities generally accorded or made available to the students of the school. We do not discriminate on the basis of race, color, national, and ethnic origin in administration of our educational policies, admissions policies, or any other school-administered programs.

New Student Application